The efficacy of intralesional vitamin D3 injection in the treatment of cutaneous warts: A clinical therapeutic trial study

Abstract Background The human papillomavirus that causes warts is usually harmless, and it can infect any part of the skin or mucous membranes. Despite the availability of several treatments, warts often return, and scarring, pigmentation changes, and recurrence are all possible side effects. Aim Intralesional vitamin D3 was employed as an immunotherapy for cutaneous warts in the current investigation. Materials and Methods In Al‐Sadr Medical City in the city of Al‐Najaf Al‐Ashraf, a skin clinic conducted a therapeutic clinical experiment. A total of 204 cutaneous warts were examined in 40 patients (14 men and 26 females). Vitamin D3 solution of the dose (600 000 IU) was injected into the lesions' bases, with 0.2 mL per patient. Each session could only inject up to five warts. The injections were given every 2 weeks for a total of four times. Instructing patients to forego the use of any topical or oral medication was also a part of the protocol. Each patient was evaluated for recurrence risk before each therapy and then again 6 months later. Result and Discussion There was a wide range of patient ages in this study, from 20 months to 52 years. About 65% of the cases included females. When looking at the many kinds of warts, the most prevalent was the common wart (71.6%). After four treatments, a positive response was considered to have occurred when all lesions had disappeared, a partial response when more than half of the lesions had disappeared, and no reaction when less than half of the lesions had disappeared. The final tally was 81.9% for those who responded in whole, 11.3% for those who responded partially, and 6.9% for those who did not respond at all. Next‐session complete response rates were 12.7%, 29.9%, 54.9%, and 81.9%, respectively. Thirteen people experienced adverse symptoms, most noticeably minor swelling and itching. Within 6 months of follow‐up, warts had completely disappeared for all patients with a partial or modest response except one who had no reaction. Conclusion Vitamin D3 administered intralesional is an effective and low‐cost treatment for cutaneous warts.


INTRODUCTION
Warts on the skin are benign tumors caused by keratinocyte infection with the human papillomavirus (HPV). 1 HPV infection is widespread and usually causes no symptoms, but pathological HPV infection can be very dangerous and difficult to treat. 2 HPV-related warts and cancers may be particularly troublesome for patients with chronic immune suppression, such as those with hereditary immunodeficiency or who have just received a transplant and are on large doses of immune suppression medication. 3 Subclinical, latent, and clinical HPV infection all exist.
As a result, subclinical abnormalities are only detectable through the use of diagnostic aids (e.g., acetic acid soaking). Clinically normal skin may harbor the HPV virus or another viral genome, a condition known as latent infection. Gross examination of a patient reveals lesions. 4 PVs have a high rate of causing chronic infections, suggesting that HPVs have evolved strategies to evade immune surveillance. 5 The cellmediated immunity is the primary defense against warts. Stimulating the immune system is the best way to get rid of warts, whereas chronic problems of cell-mediated immunity increase the severity and prevalence of verruca and the risk of cancers due to HPV. 6 Resolving plane warts have been studied, and the results demonstrate an infiltration of Langerhans cells, phagocytes, and lymphocytes, including suppressor and helper T cells, as well as satellite-cell necrosis, all of which are consistent with a cell-mediated assault. 7 Nearly two thirds of cutaneous warts spontaneously retreat within 2 years, and the sites of numerous infections commonly regress simultaneously, despite the relative success of papillomaviruses in evading the immune response. 8 The clinical appearance of HPVrelated skin lesions varies widely. It was assumed that the host, the age of the lesions, and the anatomical location of the lesions all played a role in this previously. 9 Exophytic, hyperkeratotic, domeshaped papules, or plaques are the typical appearance of common warts. Although these warts can appear anywhere on the skin's surface, they are most frequently found on the palms and fingers, as well as other areas that are prone to damage, such as the elbows and knees. A linear pattern of warts may develop after autoinoculation via scratching. 10 There is currently no reliable, effective, or virucidal method of treating cutaneous warts by either destructive or medicinal methods. 11 Salicylic acid induces an inflammatory reaction and has a keratolytic impact, both of which serve to reduce the thickness of the wart. This was confirmed in a placebo-controlled analysis of six cases; patients given the real treatment were 75% successful, whereas those given the placebo were 48% successful. 12 Using a TCA 80%-90% solution in the office is a popular therapy that has devastating local effects on tissue.
TCA can be used throughout pregnancy and has no systemic harmful effects, but scarring may occur after cutaneous injury.
Podophyllin, a resin extracted from plants, is loaded with many harmful chemicals in unknown proportions. Podophyllotoxin is the most potent of these chemicals. Mucosal surfaces, as opposed to keratinized ones, are more vulnerable to their impacts. They have an antimitotic impact by interfering with the development of the spindle on that chromosomes align during mitosis. 13 A 5% of 5-FU solution applied under occlusion once daily per a month is more effective than a placebo; however, periungual administration can lead to onycholysis. 14 Even though hyperpigmentation, erosion, and erythema may be manageable side effects of 5-FU alone cream or ointment under occlusion, the treatment's potential effectiveness should not be discounted. 14 Intralesional use of 2% zinc sulfate proved beneficial in treating stubborn warts. Most likely working through necrosis and inflammation, the drug had an 81% success rate after the first injection and a 98% success rate after 2 weeks after the third injection. 15 Bleomycin injections are placed directly into the wart. Injections are quite unpleasant and may necessitate the use of local anesthetic. 16 More than 60% of warts cleared up after intralesional injections of 5-fluorouracil at a dose of 40 mg/mL once weekly until 4 weeks. 17 When taken orally, zinc may stimulate the immune system and cause warts to fall off.
Research conducted in Iraq found that patients with resistant warts responded well to oral zinc sulfate 10 mg/kg/day up to 600 mg in three separate doses over the course of 1-2 months. The success rate in curing patients was 89%. The adverse effects included vomiting, nausea, and epigastric discomfort, and the mechanism of action was either the restoration of normal zinc levels or the stimulation of the immune system through its immunomodulating activity. 15 Vitamin D, which is fat soluble, acts on the endocrine, autocrine, and paracrine systems. Vitamin D's endocrine functions typically include maintaining normal serum calcium levels. Cell types that express vitamin D nuclear receptors are the target of vitamin D's unique autocrine and paracrine activities. Potential effects include inducing cell differentiation, suppressing cell proliferation, and causing apoptosis, all of which may play important roles in immunology, cancer, and many organ systems. 18 Modifying antigen presentation by dendritic cells (DC) or macrophages is one potential mechanism by which vitamin D influences the innate immune response to pathogens. Treatment with calcitriol has been demonstrated to decrease antigen presentation, restrain DC maturation, and mediate a tolerogenic T-cell response, suggesting that these cells have vitamin D receptors (VDRs). 19 Calcitriol inhibits cell proliferation and regulates cytokine synthesis, and T-helper cells appear to be a primary target. 20 Calcitriol suppresses Th1 cytokines and stimulates Th2 cytokines in vitro. 21 Vitamin D also affects IL-17-secreting T cells (Th17 cells). In addition to helper T cells, calcitriol is a powerful inducer of regulator T cells (Tregs).

Recent research has highlighted the role of regulatory T cells (Tregs)
in mediating vitamin D's immunoregulatory effects. 22 The objective of this research was to examine the effect of intralesional vitamin D3 in the management of cutaneous warts.

PATIENTS AND METHODS
The research was conducted between April 2021 and March 2022 in the dermatology department of Al-Sadr Medical City in the city of Al-Najaf Al-Ashraf.

Ethical review board
The Arab Board of Dermatology's scientific council gave their authorization before the study could proceed. The patients and their parents were given comprehensive information about the study, including the treatment modality and duration of participation. All patients gave their informed consent about pronunciation before taking part in the trial.
The purpose of this research is to determine whether or not the intralesional vitamin D3 is useful in the treatment of skin warts. Patients who met the inclusion and exclusion criteria underwent a thorough physical examination to determine the location, size, type, and number of lesions. Every patient was given a set of color photos taken at the start and before each treatment.

Treatment
Since the first session of vitamin D3 injections without Anastasia caused pain for all patients, 0.2 mL of lignocaine (20 mg/mL) was injected into the base of each wart slowly using a gage 27 needle.
This was followed by the slow injection of 0.2 mL of vitamin D3 solution (600 000 IU; 15 mg/mL) ( Figure 1). In certain cases, as many as five warts might be injected during a single session. The injections were repeated every 4 weeks until the condition improved significantly or no longer required treatment. Patients were instructed to refrain from using any external or internal wart remedies following treatment.
Lesions were measured before and after therapy to record how well the lesions responded to the treatment. To detect any recurrence, the patients were monitored for a full 6 months after their final injection. Before and after measurements of all cutaneous warts were taken during treatment in order to evaluate the efficacy of the procedure. Photographic measurements were taken at the beginning, after 8 weeks, and after 6 months for the clinical evaluation. Patients were considered to have a partial response if they experienced a 50% or higher reduction in the size and quantity of warts and to have not responded if they experienced a decrease of less than 50%.

Quantitative research
For this study, data from 40 individuals with cutaneous warts were input and analyzed using SPSS V. 25 (SPSS 25

RESULTS
The average age of the 40 patients in this study was 12.8-20.1 (range: 20 months-52years) old, whereas the median age was 18, and the interquartile range was 10-27. There were 1.86 times as many women as there were men involved in the cases. Warts often lasted anywhere from 4 months to 3 years on average (Table 1 and Figure 2). There were a total of 204 cutaneous warts among the study population, as evidenced by the frequency distribution (Table 2). The majority (146/71.6%) of the 204 warts were common warts; other forms included plantar warts (23%), periungual warts (9%), and a single filiform wart (0.5%) ( Table 3 and Figure 3).
The mean size of the 204 warts was reduced from 6.4 mm at the beginning of therapy to 3.9 mm by the end of treatment, a decrease that was statistically significant (P0.001). The trend of the reduction in mean size at succeeding sessions is shown in Figure 4. Complete resolution was seen in 167/204 (81.9%) warts, partial resolution was shown in 23/11.3% warts, and no resolution was seen in 14/6.9% warts after the fourth treatment session, as described in the study (Table 4). Using cross-tabulation, we compared patients whose warts were smaller than 5 mm in diameter to those whose warts were larger than 5 mm in diameter; we found no statistically significant correla-tion between wart size and treatment outcome (p > 0.05) ( Table 6 and Figure 5). There was also a statistically significant (p = 0.001) correlation between the type of wart and the degree to which it responded to treatment; patients with periungual warts had a 100% complete response rate, those with plantar warts had a 91.5% complete response rate, and those with common warts showed a 77.4% complete response rate (Table 7). There were no statistically significant differences in the mean duration of warts across the response rate subgroups (complete, partial, and no response), though the none response subgroup had a longer mean duration (1.57 years) than the partial response (1.20 years) or the complete response (1.38 years) ( Figure 6), (Figures 7-10  site swelling, which went down on its own within a week. Five (38.5%) patients experienced itching, and one (7.7%) patient experienced dyspigmentation, which went away on their own after 3 weeks (Table 9).

TA B L E 6
Cross-tabulation for the relationship between size of wart and response to treatment for 204 cutaneous warts of 40 patients.

DISCUSSION
To put it simply, warts are a harmless, widespread, and frequently recurring HPV infection of the skin and mucous membranes. 1 Most people ask for treatment for warts because they are cosmetically bad appearance and occasionally painful, especially when they are located on the soles of the feet. 23 Cryotherapy and electrocautery are just two examples of the damaging treatments that may be necessary when treating many warts at once, especially palmoplantar. Both scarring and discoloration can be the end effect of such invasive operations.
Warts are unsightly, can be embarrassing, and have a high recurrence rate and resistance to common treatments. Due to its ability to increase the body's immune response against HPV, immunotherapy is currently the most effective method for treating warts. Comparatively few occurrences recur when compared to other destructive modalities. 23 Immune therapy has been explored with a wide range of antigens and vaccines, including bleomycin, Candida albicans, PPD, MMR, and mycobacterium W vaccine. 24

F I G U R E 9
A girl of 20 years old with multiple common warts in hand shows complete response: (a) before treatment, (b) 6 weeks after three treatment sessions. showed partial reaction, and 3 (0%) showed no response at all. 27 Only four of the 204 lesions studied in this investigation had only a partial response, but among the planter warts (47/204) that did respond, the complete response rate was significantly greater (91.5% vs. 68.6%).

Moscarelli et al. successfully cured a refractory wart in a 41-
year-old patient with a history of renal transplantation with calcitriol solution. 28 Calcipotriene ointment was shown to be effective in the total elimination of a patient's anogenital wart, as demonstrated by Rind et al. 29 Although the vitamin D3 employed in these two case studies was applied topically (in the form of a solution or ointment), we administered it intralesional and did not include individuals who were immunocompromised.
Of the 60 patients enrolled in the study by Naresh  Recurrence of palmoplantar warts occurred in only one patient. 31 The current trial allowed for the treatment of up to five lesions per session. with half assigned to get intralesional MMR vaccine into the largest wart and the other half receiving intralesional vitamin D3 in up to five warts at once. Each group participated in the session no less frequently than every 3 weeks, and for no more than 6 total sessions. The numbers showed that in group A, 80% of patients were completely cured, whereas 6.67% of patients in group B experienced the same. Neither group differed from the other in any meaningful way. 34

CONCLUSION
When it comes to treating cutaneous warts, whether they be single or many, an intralesional injection of vitamin D3 is a highly successful and inexpensive immunotherapy option.

CONFLICT OF INTEREST STATEMENT
We declare that on one of the authors has conflict of interest.

FUNDING INFORMATION
The funding sources for the work are at the author's personal expense.

DATA AVAILABILITY STATEMENT
Not applicable.